Predictors of Primary Care Follow-Up After a Pediatric Emergency Visit for Asthma

Objective. Prior studies have reported low rates of follow-up with a primary care provider (PCP) after emergency department (ED) treatment for asthma. We sought to identify predictors associated with PCP follow-up. Methods. As part of a randomized trial we surveyed parents of children aged 2–18 years being discharged after ED asthma treatment. Parents described their child's asthma history and perceived benefits and barriers to making a PCP follow-up visit. Bivariate tests and multivariable logistic regression were used to determine association with completion of a follow-up visit within 4 weeks of the ED visit. Results. A total of 278 subjects (N = 278)were enrolled; 55% saw their PCP within 4 weeks of the ED visit. Baseline factors that were associated with an increased likelihood of follow-up included a recent hospitalization, more than one ED visit for asthma in the past year, the parent's assessment that the child has “very severe” asthma, and current daily use of a controller medication. Parental beliefs that taking daily asthma medications and finding out about the causes of asthma attacks were very important and were also associated with increased PCP follow-up. Parents were less likely to follow up if they reported a lack of convenient appointments or prolonged waits in the PCP office. A multivariable model including clinical factors, parental beliefs, and the study intervention predicted the likelihood of follow-up. Conclusions. Parental beliefs about asthma severity, the benefits of controlling asthma, and organizational barriers to seeing a PCP were associated with follow-up after a pediatric ED visit for asthma.     

Predictors of Primary Care Follow-Up After a Pediatric Emergency Visit for Asthma

Objective. Prior studies have reported low rates of follow-up with a primary care provider (PCP) after emergency department (ED) treatment for asthma. We sought to identify predictors associated with PCP follow-up. Methods. As part of a randomized trial we surveyed parents of children aged 2-18 years being discharged after ED asthma treatment. Parents described their child's asthma history and perceived benefits and barriers to making a PCP follow-up visit. Bivariate tests and multivariable logistic regression were used to determine association with completion of a follow-up visit within 4 weeks of the ED visit. Results. A total of 278 subjects (N = 278)were enrolled; 55% saw their PCP within 4 weeks of the ED visit. Baseline factors that were associated with an increased likelihood of follow-up included a recent hospitalization, more than one ED visit for asthma in the past year, the parent's assessment that the child has “very severe” asthma, and current daily use of a controller medication. Parental beliefs that taking daily asthma medications and finding out about the causes of asthma attacks were very important and were also associated with increased PCP follow-up. Parents were less likely to follow up if they reported a lack of convenient appointments or prolonged waits in the PCP office. A multivariable model including clinical factors, parental beliefs, and the study intervention predicted the likelihood of follow-up. Conclusions. Parental beliefs about asthma severity, the benefits of controlling asthma, and organizational barriers to seeing a PCP were associated with follow-up after a pediatric ED visit for asthma.     

Cardiac Pacing During Neurocardiogenic (Vasovagal) Syncope

Cardiac Pacing and Neurocardiogenic Syncope. Head-up tilt testing is increasingly being used as a diagnostic modality in patients with unexplained syncope who are thought to have neurocardiogenic (vasovagal) mechanisms of syncope. Although large-scale placebo-controlled trials are still awaited, pharmacologic therapy is usually effective in preventing syncope or presyncope in this patient population. However, the role of permanent pacemaker therapy remains controversial. Because hypotension is usually associated with paradoxical bradycardia and occasionally asystole, it has been argued that permanent pacemaker therapy may be useful in preventing syncope and, thus, injury, in the so-called "malignant vasovagal cardioinhibitory response" in which the onset of syncope is thought to be abrupt. The onset of hypotension, however, usually precedes bradycardia during neurocardiogenic syncope, and pacing may thus not prevent syncope or presyncope in these patients. The role of cardiac pacing in patients with neurocardiogenic syncope is reviewed.     

Refinement of an Instrument to Evaluate Parental Attitudes About Follow-Up Care After an Acute Emergency Department Visit for Asthma

Introduction. Prompt follow-up after emergency department (ED) care for asthma allows the primary care provider (PCP) and family to review factors that led to the ED visit, update current care plans, and plan for prevention of future exacerbations. Methods. The Initial Questionnaire to assess parental impressions of Pros and Cons of follow-up was administered to parents who brought their children to the ED for treatment of an acute asthma exacerbation (N = 309). After a planned interim analysis, 19 new items were generated, and this Expanded Questionnaire was given to 198 parents. Principal Component Analysis (PCA) was used to identify well-defined items and discard ambiguous and confusing items. Results. PCA of the Expanded Questionnaire revealed 18 of 43 items related to four dimensions of parents' Pros and Cons for obtaining follow-up care. Four distinct categories were identified: two Pros and two Cons. Pro items related to practical things parents get from a follow-up visit and to positive parental beliefs about follow-up care. Con items emphasized practical considerations that make it difficult to go to a follow-up visit and identified the misconception that follow-up is not necessary for asymptomatic children. In addition, two distinct clusters of parents were identified: those that value and those that do not value follow-up care. Conclusion. We developed an 18-item measure that assesses Pros and Cons of follow-up care for asthma following emergency care, which has four reliable factors: Pro Practical, Pro Attitude, Con Practical, and Con Attitude. This questionnaire may help guide interventions to change perceptions of the need for follow-up. Attention to increasing Pros among those who are reluctant to attend follow-up care may be especially effective.     

Refinement of an Instrument to Evaluate Parental Attitudes About Follow-Up Care After an Acute Emergency Department Visit for Asthma

Introduction. Prompt follow-up after emergency department (ED) care for asthma allows the primary care provider (PCP) and family to review factors that led to the ED visit, update current care plans, and plan for prevention of future exacerbations. Methods. The Initial Questionnaire to assess parental impressions of Pros and Cons of follow-up was administered to parents who brought their children to the ED for treatment of an acute asthma exacerbation (N = 309). After a planned interim analysis, 19 new items were generated, and this Expanded Questionnaire was given to 198 parents. Principal Component Analysis (PCA) was used to identify well-defined items and discard ambiguous and confusing items. Results. PCA of the Expanded Questionnaire revealed 18 of 43 items related to four dimensions of parents' Pros and Cons for obtaining follow-up care. Four distinct categories were identified: two Pros and two Cons. Pro items related to practical things parents get from a follow-up visit and to positive parental beliefs about follow-up care. Con items emphasized practical considerations that make it difficult to go to a follow-up visit and identified the misconception that follow-up is not necessary for asymptomatic children. In addition, two distinct clusters of parents were identified: those that value and those that do not value follow-up care. Conclusion. We developed an 18-item measure that assesses Pros and Cons of follow-up care for asthma following emergency care, which has four reliable factors: Pro Practical, Pro Attitude, Con Practical, and Con Attitude. This questionnaire may help guide interventions to change perceptions of the need for follow-up. Attention to increasing Pros among those who are reluctant to attend follow-up care may be especially effective.     

Outcomes of Chronic Pancreatitis in the Emergency Department

Objectives

Chronic pancreatitis (CP) is a debilitating chronic illness. We sought to assess the most common reasons patients with CP visit the Emergency Department (ED), the disposition of ED visit [admission, discharge, death], and evaluate predictors of admission and discharge.

Methods

Within the Health Care Utilization Project Nationwide Emergency Department Sample (NEDS), we focused on patients, 18 years and older, presenting to the emergency department with CP (ICD-9 code 577.1) (2006–2009). Model was fitted to predict the likelihood of admission.

Results

Overall, a weighted sample of 638,310 patients visits for CP were identified, of which 399,559 (62.6%) were admitted, 228,523 (35.8%) were discharged from the ED, 5572 (0.9%) discharged against medical advice, and 4656 (0.7%) had an unknown destination. Of those admitted, 4370 (0.7%) died during the hospital episode. The most associated diagnoses for ED visit were diabetes (28.8%), abdominal pain (25.4%), acute pancreatitis (22.5%), cardiac complication (11.1%), infection (10.1%), and dehydration (8.8%). Multivariable analyses revealed that older (OR?=?1.02 P?<?0.001), sicker patients (Charlson Comorbidity Index?≥?3, OR?=?2.28 P?<?0.001), patients presenting with C. difficile colitis (OR?=?23.85 P?<?0.001), alcohol withdrawal (OR?=?6.71 P?<?0.001), and acute pancreatitis (OR?=?6.46 P?<?0.001) were associated with increased odds of hospitalization.

Conclusions

In this national database, our study demonstrates that diabetes, followed by abdominal pain, acute pancreatitis and cardiac complication, were the most common diagnoses associated with ED visits in patients with chronic pancreatitis. Most patients were admitted following the ED visit. Although C. Difficile colitis was a rare associated diagnosis with an ED visit, it was the strongest predictor of admission.

     

Factors Influencing Clinical Outcomes After Revascularization in the Asymptomatic Cardiac Ischemia Pilot (ACIP)

Abstract Background and Aim The Asymptomatic Cardiac Ischemia Pilot is the first randomized trial where revascularization involved choice of either coronary bypass or angioplasty used in an early or a delayed symptom-driven approach. One-year outcomes were favorable (reduced recurrent ischemia and adverse outcomes) for an early revascularization strategy (within 4 weeks), compared with an early medical strategy when revascularization was delayed until symptom-driven. This ancillary study examined variables influencing outcomes after these 2 revascularization approaches (early vs. delayed until symptom-driven). Methods: Participants were clinically stable coronary disease patients with stress-induced and daily life ischemia who underwent revascvularization. Characteristics associated with clinical outcomes occurring within the year following revascularization were examined using Cox regression analysis. Results: A total of 262 patients received revascularization; 170 in the early approach and 92 in the delayed symptom-driven approach. Thirty-three patients had adverse outcomes (death, nonfatal myocardial infarction, or repeat revascularization) during l-year follow-up. The most important independent predictor of improved outcome during the follow-up year was attempted revascularization of ≥ 66% of vessels with significant stenosis for the early (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.09–0.67) and the delayed (RR 0.21, CI 0.08–0.58) approaches. Factors such as age, stress test results, and coronary angiographic findings did not predict clinical outcome. Conclusions: Our findings are important in the planning of a large trial with longer follow-up.